Provider Demographics
NPI:1104851963
Name:FITCH, STEPHEN M (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:M
Last Name:FITCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 CARMEN DRIVE
Mailing Address - Street 2:SUITE #111
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-3103
Mailing Address - Country:US
Mailing Address - Phone:805-987-7006
Mailing Address - Fax:
Practice Address - Street 1:1601 CARMEN DRIVE
Practice Address - Street 2:SUITE #111
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-3103
Practice Address - Country:US
Practice Address - Phone:805-987-7006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 13676103TC0700X, 103TC1900X, 103TF0000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY 136760Medicaid
CAOPL136760OtherBLUE SHIELD OF CALIFORNIA
CAPSY 136760Medicaid